What makes community health worker models for tuberculosis active case finding work? A cross-sectional study of TB REACH projects to identify success factors for increasing case notifications

Engagement and Preparedness of Urban Accredited Social Health Activists (U-ASHAs) for Delivery of Tuberculosis (TB) Care: Findings From two Cities in Maharashtra, India

Finding missing tuberculosis (TB) cases from the "under-reached" population of urban slums and connecting them with TB services is a priority and ongoing challenge for India. It requires the effective engagement of community health workers including urban Accredited Social Health Activists (U-ASHAs). The study aimed to understand the current engagement of U-ASHAs in TB care and their commensurate preparedness in terms of TB knowledge and training. An exploratory study was conducted in Mumbai and Pune cities of Maharashtra during 2022-23. The study used a mixed-methods approach, including a semi-structured survey of U-ASHAs (n = 222) and in-depth interviews with relevant stakeholders (n = 33). The statistical analysis used was descriptive statistics using MS Excel. The average age and work experience of U-ASHAs were 35.4 (21-50) years and 2.7 (0.5-6) years, respectively. They considered maternal child health services as their main portfolio and TB as an ancillary program. They were mainly involved in a biannual active case finding (ACF) and were recently envisioned as TB treatment supporters with poor clarity about other roles in TB care. Just half-day training for TB as part of 8-day general induction training, brief updates before ACFs, and the absence of an on-the-job supervisory structure resulted in TB knowledge gaps particularly for the latest diagnostic tests, adverse drug reactions, government schemes for TB patients, and contact tracing. Conclusions: Intermittent TB activities coupled with insufficient training impede U-ASHAs' functionality in TB care. Clarity of TB-related roles, integration of TB activities in daily tasks, comprehensive training, and on-the-job supervisory structures have merit in strengthening U-ASHAs' engagement in urban TB care.

Individual, community and health systems factors influencing time to notification of tuberculosis: situating software and hardware bottlenecks in local health systems

BACKGROUND

Despite several global interventions, tuberculosis (TB) remains a leading cause of death affecting millions of people globally. Many TB patients either have no access to quality care or go undetected by national health systems. Several multilevel factors account for under-detection of persons with TB. This study sought to explore patient-related software, community and health systems software and hardware factors influencing time to notification of TB in Lusaka District, Zambia.

METHODS

This was an exploratory qualitative case study that adopted a software and hardware lens of conceptualizing health systems. Data were collected from across three sites - urban and peri-urban areas: Chongwe, Kafue, and Lusaka - within Lusaka Province, Zambia. Sixteen key informants - TB corner nurses, community TB treatment supporters, and TB program managers - were interviewed. Six focus groups were held with TB patients. Data were analyzed using thematic analysis.

RESULTS

The study identified factors influencing timely TB notification, categorized into software and hardware elements. Patient-related software elements, including TB knowledge and awareness, and health-seeking behavior, are crucial for prompt notification among TB patients. In the community health system, software elements like social stigma and undesirable community attitudes towards contact tracing, and hardware elements such as unbalanced schedules, excessive workload and limited capacity of community TB treatment supporters contribute to delayed TB notification. In the formal health system, software elements like negative attitudes of health providers towards TB patients and demotivation of TB staff, and hardware elements such as high diagnostics and transportation costs, outdated diagnostics in primary care facilities, and slow referral mechanisms, can also delay TB notification.

CONCLUSION

Delays in time to TB notification are influenced by a combination of software (attitudinal and behavioral) and hardware (resource-related) elements across TB patients, community health systems, community TB treatment supporters, health providers, and TB staff. Addressing these factors, particularly social stigma, negative attitudes, and resource constraints, is crucial to improving timely TB detection and treatment.

Exploring opportunities to strengthen rural tuberculosis health service delivery: a qualitative study with health workers in Tibet autonomous region, China

OBJECTIVES

This qualitative study aimed to explore opportunities to strengthen tuberculosis (TB) health service delivery from the perspectives of health workers providing TB care in Shigatse prefecture of Tibet Autonomous Region, China.

DESIGN

Qualitative research, semi-structured in-depth interviews.

SETTING

The TB care ecosystem in Shigatse, including primary and community care.

PARTICIPANTS

Participants: 37 semi-structured interviews were conducted with village doctors (14), township doctors and nurses (14), county hospital doctors (7) and Shigatse Centre for Disease Control staff (2).

RESULTS

The three main themes reported include (1) the importance of training primary and community health workers to identify people with symptoms of TB, ensure TB is diagnosed and link people with TB to further care; (2) the need to engage community health workers to ensure retention in care and adherence to TB medications; and (3) the opportunity for innovative technologies to support coordinated care, retention in care and adherence to medication in Shigatse.

CONCLUSIONS

The quality of TB care could be improved across the care cascade in Tibet and other high-burden, remote settings by strengthening primary care through ongoing training, greater support and inclusion of community health workers and by leveraging technology to create a circle of care. Future formative and implementation research should include the perspectives of health workers at all levels to improve care organisation and delivery.

A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia

BACKGROUND

Community health workers (CHWs) have demonstrated capability to improve various health indicators, however, many programmes require support in meeting their objectives due to subpar performance and a high rate of CHW attrition. This systematic review investigated the types of CHWs, their workloads, and supervision practices that contribute to their performance in different countries.

METHODS

The search was carried out in November 2022 in Medline, Embase, and Neliti for studies published in Indonesian or English between 1986 and 2022 that reported public health services delivered by CHWs who live and serve the community where they live but are not considered health professionals. The findings were synthesised using a thematic analysis to assess key factors influencing the performance of CHWs.

RESULTS

Sixty eligible articles were included in this review. CHWs were responsible for more than two diseases (n = 35) and up to fifteen, with more than eighteen activities. Their roles covered the human life cycle, from preparation for pregnancy, care for newborns, health for children, adolescents, and productive age to elderly individuals. They were also involved in improving environmental health, community empowerment, and other social issues hindering access to health services. They carried out promotive, preventive, and curative interventions. The CHW-population ratio varied from eight to tens of thousands of people. Some CHWs did not have a clear supervision system. Challenges that were often faced by CHWs included inappropriate incentives, inadequate facilities, insufficient mentoring, and supervision, many roles, and a broad catchment area. Many studies revealed that CHWs felt overburdened and stressed. They needed help to balance their significant work and domestic tasks.

CONCLUSIONS

Effective planning that considered the scope of work of CHWs in proportion to their responsibilities and the provision of necessary facilities were crucial factors in improving the performance of CHWs. Supportive supervision and peer-supervision methods are promising, however, any CHW supervision required a detailed protocol. This systematic review emphasised the opportunity for CHW management system improvement in Indonesia.

Finding and treating both tuberculosis disease and latent infection during population-wide active case finding for tuberculosis elimination

In recognition of the high rates of undetected tuberculosis in the community, the World Health Organization (WHO) encourages targeted active case finding (ACF) among "high-risk" populations. While this strategy has led to increased case detection in these populations, the epidemic impact of these interventions has not been demonstrated. Historical data suggest that population-wide (untargeted) ACF can interrupt transmission in high-incidence settings, but implementation remains lacking, despite recent advances in screening tools. The reservoir of latent infection-affecting up to a quarter of the global population -complicates elimination efforts by acting as a pool from which future tuberculosis cases may emerge, even after all active cases have been treated. A holistic case finding strategy that addresses both active disease and latent infection is likely to be the optimal approach for rapidly achieving sustainable progress toward TB elimination in a durable way, but safety and cost effectiveness have not been demonstrated. Sensitive, symptom-agnostic community screening, combined with effective tuberculosis treatment and prevention, should eliminate all infectious cases in the community, whilst identifying and treating people with latent infection will also eliminate tomorrow's tuberculosis cases. If real strides toward global tuberculosis elimination are to be made, bold strategies are required using the best available tools and a long horizon for cost-benefit assessment.